The inquest was told that Dr Rowe had a strict "10-minute rule" where patients who were more than 10 minutes late for appointments were turned away.

Ellie-May collapsed at home at 10.30pm that night and died in hospital, with a pathologist later finding that her death had been caused by bronchial asthma.

A letter sent by her consultant to the Grange Clinic - received by Dr Rowe - months before her death warned she was at risk of "an episode of severe/life-threatening asthma".

The girl suffered a wheezy chest from a young age and was first admitted to hospital in November 2011, two months before her second birthday.

She was prescribed inhalers but was admitted to hospital five times between February 2013 and March 2014. In May 2014, her hospital consultant wrote the letter to her surgery to highlight her "life-threatening condition".

"Ellie-May has previously had severe exacerbations of asthma requiring admission to the high dependency unit," it said.

Shanice Clark arrives at Newport Coroner's Court ahead of the hearing into her daughter's death (Image: Athena Picture Agency Ltd)

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"This places her at risk of having another episode of severe/life-threatening asthma."

Dr Rowe did not place this prominently on Ellie-May's medical records. Ellie-May continued to attend the surgery regularly for treatment for her asthma, including steroids.

Miss Clark kept Ellie-May off school in the week before her death and she was taken on January 22 to see a doctor who said her condition did not require steroids.

On January 26, Ellie-May's school phoned at 1.30pm reporting that she had required her inhaler. When Miss Clark collected her at 3pm, a teacher advised her to take Ellie-May to a doctor.

Little Ellie-May Clark collapsed and died from a sudden asthma attack hours after her GP refused to see her (Image: WALES NEWS SERVICE)

"During the short walk from school, Ellie was crying, asking for her pink medication (steroids) and asking to be taken to the doctor," Mrs James said.

"Ellie asked her mother to carry her because she couldn't walk."

Miss Clark phoned the surgery at 3.30pm reporting that her daughter was wheezing and could not walk but was not phoned back until 4.35pm, when she was offered the 5pm appointment.

After arriving at the surgery, Ellie-May and her mother waited for a receptionist to finish a phone call and deal with a patient in front of them in the queue. They spoke to receptionist Ann Jones between 5.10pm and 5.18pm.

"Dr Rowe replied that she wouldn't see Ellie as she was late and she would need to come back the following day," Mrs James said.

Neither Mrs James nor Dr Rowe asked why Ellie-May was late or the reason for her emergency appointment. The doctor did not open Ellie-May's clinical notes or ask a colleague to see her.

Miss Clark said Ellie-May was upset after leaving the surgery and asked: "Why won't the doctor see me?"

She told the inquest she did not believe her daughter needed to go to hospital, adding: "Obviously now I would do things differently."

They returned to the family home in Malpas, Newport, where Ellie-May went to bed at about 8pm.

Miss Clark checked on her daughter every 10-15 minutes and went in at 10.30pm after hearing her coughing.

She immediately called 999 after seeing that Ellie-May's face and hands had turned blue and she girl was taken to the Royal Gwent Hospital , where she was pronounced dead a short time later.

A post-mortem examination by Andrew Bamber found Ellie-May had died from bronchial asthma and may have suffered a seizure before her death due to a lack of oxygen.

Recording a narrative conclusion, the coroner said: "From the evidence before me, it is not possible for me to determine with certainty whether an earlier intervention would have altered the outcome for Ellie but nonetheless Ellie should have been seen by a GP that day and she was let down by the failures in the system.

Justin Chisnall reads a statement on behalf of the family after the ruling (Image: Athena Picture Agency Ltd)

"Ellie-May Clark died of natural causes where the opportunity to provide potentially life-saving treatment was missed.

"Ellie's care was disjointed. There was no one doctor or clinician allocated to oversee Ellie's long-term management or care even though she suffered with a life-threatening condition.

"She was dealt with by three doctors in the surgery in five days.

"Had she been seen by one doctor, things maybe been different for Ellie.

"There was a delay of over an hour in calling Miss Clark back to offer her an emergency appointment.

"It is unacceptable that patients should be refused to be seen at an emergency appointment without any clinical assessment of their condition or any advice given.

"Especially when that patient is a five-year old child with a history of severe acute asthma."

The Grange Clinic in Newport where Ellie-May Clark was a few minutes late for her appointment (Image: Google Maps)